Good Samaritan Society – Alliance

The Centers for Medicare and Medicaid Services (CMS) and the state of Nebraska routinely conduct investigations and surveys at every nursing facility statewide. Their efforts help identify serious concerns, violations and deficiencies occurring inside the nursing home that affect the health and well-being of the residents. In some incidents, the surveyors will issue one or more citations and call for prompt corrective action.

At some locations, the underlying problems of the nursing facility that led to the discrepancies make it extremely difficult to ensure that any improvement made at the Home remains permanent. In the most deplorable cases, the nursing home will be placed on a national watchlist and designated a Special Focus Facility (SFF). This special designation will result in numerous additional surveys, investigations, and inspections throughout the year to determine if the nursing home has made any significant improvement to the level of care they provide.

Nearly two years ago, Good Samaritan Society – Alliance was placed on the national watch list and designated a Special Focus Facility. Recent updated regulatory information reveals that the nursing facility has yet to make significant improvements, corrections, and adjustments or develop, implement and enforce acceptable standards of care. Likely, the Home will remain on the list for many more years to come. Some of the serious concerns are listed below.

Good Samaritan Society – Alliance

This facility is a 77-certified bed ‘for profit’ long-term care home providing services and cares to the residents of Alliance and Box Butte County, Nebraska. The Center is located at:

1016 E. 6th St.Alliance, NE 69301(308) 762-5675

In addition to providing around-the-clock skilled nursing care, the facility also offers:

Respite care

Post-acute rehabilitation services

Men’s behavioral care

Memory care

Traumatic brain injury care

Huntington’s disease care

Penalties

State and federal regulators have a legal obligation to issue monetary penalties to facilities with egregious violations of nursing home regulations. Within the last three years, Good Samaritan Society – Alliance received a $19,013 fine on July 6, 2016. Additionally, Medicare denied a request for payment for services provided on May 23, 2017, due to substandard care.

Current Nursing Home Resident Safety Concerns

The publicly available information provided on the federal Medicare.gov website details safety concerns, health violations, dangerous hazards, filed complaints, opened investigations, and incident inquiries at every nursing home in the United States. Many individuals and families use this valuable data as an effective way to determine where to place a loved one who requires the best level of nursing, medical and hygiene care. The information is provided through a star rating summary system.

Currently, Good Samaritan Society – Alliance maintains a below average overall two out of five stars compared to all other nursing homes nationwide. This ranking includes one out of five stars for health inspections, three out of five stars for staffing, and five out of five stars for quality measures. Some of the major concerns over resident safety are listed below.

Failure to Develop, Implement and Enforce a Complete Care Plan That Meets All the Resident’s Needs

In a summary statement of deficiencies dated April 12, 2017, the state surveyor noted that the facility had failed to “develop a Care Plan to address [a resident’s] skin breakdown.” A review of the resident’s Minimum Data Set revealed that the resident “required limited assistance with one staff person for bed mobility, transfer, walking, dressing, and personal hygiene.” The resident’s Care Area Pressure Ulcer triggered a review as was indicated on the Plan of Care.

A review of the resident’s April 2017 Treatment Record revealed that the resident “had a dressing change order to the left inner thigh.” However, the resident’s Care Plan dated February 21, 2017 “revealed no documentation of the problem, goal, or interventions to address the skin breakdown.” The investigator interviewed the facility’s Assistant Director of Nursing who stated that the resident “did have a skin breakdown on the left inner thigh and the facility was treating.” The assistant also “confirmed the skin breakdown was not addressed on [the resident’s] Care Plan and should have been.”

Failure to Provide Necessary Care and Services to Treat an Abnormal Skin Condition

In a summary statement of deficiencies dated August 23, 2017, the state investigator noted that the facility had failed to “ensure wound care interventions ordered by the medical practitioner were implemented to promote healing of an abnormal skin condition.” The surveyor reviewed the resident’s Pulmonary Transmission Report of June 27, 2017, recorded by the Physician Assistant (PA). The document revealed that the resident “was assessed by the PA in a clinic for a chief complaint of a boil on the right buttock. The physician’s assistant documented that the resident had limited mobility, and a family member described a bleeding lesion on the patient’s right buttock.”

The Physician Assistant documented the breakdown as being very superficial before applying “a non-adherent dressing and some triple antibiotic ointment to the area.” The physician described “that written orders were given to the facility to change the dressing once daily and as needed over the next week, and to use a specialized pressure relief cushion in the [resident’s] wheelchair and recliner.” It further documents “to give [the resident] an air mattress, and help [with] position changes every two hours while sleeping.” The physician’s assistant also documented that “the facility was instructed to watch for signs of infection and return for follow-up in one week.”

The surveyor reviewed the resident’s Medication Records and Treatment Records from June 1, 2017, through July 31, 2017. The records revealed that “there was no documentation or order transcription for the use of [a specialized pressure relief cushion] in the wheelchair and recliner or use of an air mattress on the treatment or medication records.”

A follow-up visit with the Physician Assistant on June 27, 2017, confirmed that the resident was “found to have a round reddened area on the right buttock. The Physician Assistant stated [they] provided written orders for the [specialized] cushion and air branches along with dressing changes and antibiotic ointment to treat the condition.” The return visit showed that the area “had not improved between June 27, 2017, and July 5, 2017, and [that] the resident came to the appointment without [the specialized] cushion in the wheelchair and no dressing cover on the site.”

The physician’s assistant also stated that “the resident reported the facility had not added an air mattress on the bed.” The Physician Assistant initiated a call to the facility to speak with “the facility’s Charge Nurse who reported the dressings were falling off and verified [the specialized] cushion and air mattress had not been initiated.” By July 10, 2017 “there was no other documentation indicating the facility had added the [specialized] cushion. There was no documentation regarding the air mattress to the resident’s bed until the Treatment Record recorded a nursing order to check the mattress initiated on July 10, 2017.”

Failure to Provide Proper Care for Residents Requiring Special Services

In a summary statement of deficiencies dated May 23, 2017, the state investigator noted that the facility had failed to “ensure that oxygen was administered as ordered.” The state investigator reviewed the resident’s May 2017 Treatment Record that revealed a March 29, 2017 [dcotr’s] order “for oxygen at 1 Liter per nasal cannula (tubing used to deliver oxygen into the nose) during the day and 4 Liters per nasal cannula at night.”

However, a further review revealed that from May 1, 2017, through May 15, 2017, except on May 11, and again on May 19, 2017 “the resident used 2 liters of oxygen on the day shift and 3 liters of oxygen on May 18, 2017.” Further review by the investigator “revealed the resident used 3 liters of oxygen on the night shift on May 17, 2017. The surveyor interviewed the Director of Nursing on May 23, 2017, after the deficiency was identified. The Director “confirmed that the nurses were to administer the action as ordered to meet the needs of the resident.”

Failure to Maintain and Environment Free of Accident Hazards

In a summary statement of deficiencies dated May 23, 2017, the state investigator noted that the facility had failed to “ensure unattended oxygen concentrators were turned off… Which could potentially fuel a spark fire” and ensure “toilet riser carriage bolts were covered to prevent sharp metal from potentially causing the skin injury for [a resident].”

An observation was made of a resident’s room on the afternoon of May 17, 2017, while “the resident was out of the room eating in the dining room, and the resident’s oxygen concentrator was running at two liters of oxygen with the cannula draped across the bed. The concentrator was observed unattended.” A follow-up observation was made 15 minutes later while “the resident was out of the room eating in the dining room and the resident’s oxygen concentrator was running at two liters of oxygen with the cannula draped across the two-drawer cabinet next to the resident’s recliner. The concentrator was observed unattended.”

Additional observations were made of the resident’s oxygen concentrator being left unattended on May 18, 2017, at 8:30 AM, and on May 22, 2017, at 9:30 AM. Later on the afternoon of May 22, 2017, observations were made with the Director of Nursing that revealed two residents “in the dining room eating [while their] concentrators in their rooms were left on an unattended.” The Director “verified the concentrators were unattended and posed a potential risk of creating a hazard for fire by oxygenating the rooms.”

In a separate observation made on May 17, 2017, of a resident’s bathroom revealed “a stool riser was fastened to the toilet by two carriage bolts. Further observation revealed uncovered carriage bulkheads atop the service area of the stool riser with jagged, rough edges.”

Failure to Develop a Program That Investigates, Controls and Keeps Infection from Spreading

In a summary statement of deficiencies dated May 23, 2017, the state investigator noted a failure of the facility “to ensure that an oxygen mask was cleaned and covered after use to reduce the risk of cross-contamination.” Observations were made of a resident’s room “on May 17, 2017, at 2:30 PM, May 18, 2017, at 10:00 AM, and on May 22, 2017, 11:00 AM.” The observations “revealed the oxygen mask uncovered on the bedside table attached to a …machine (used with oxygen at night to treat respiratory failure).”

The investigator interviewed the facility’s Infection Control Nurse and License Practical Nurse who confirmed that “the oxygen mask was to be cleaned and covered after use to reduce the risk of cross-contamination.”

Failure to Provide Care for Residents That Keeps or Builds Their Dignity and Respect of Individuality

In a summary statement of deficiencies dated May 23, 2017, the state surveyor noted that the facility had failed to “ensure one resident was transferred from the facility by emergency responders using a discrete exit.” An observation was made of the resident at 11:50 AM on May 18, 2017, while “facility residents were seated in the dining room awaiting the noon meal. The dining room was observed adjacent to the front entrance of the facility. During the observation, several residents were observed discussing the ambulance and flashing lights outside the south window the dining room.”

“Further observation by the surveyor revealed the resident “was placed onto a gurney and transported from the resident’s room down the hallway and through the dining room and front entrance before being loaded into the ambulance. The resident’s transport through the dining room into the lobby and exit door was an unobstructed view by all the residents, staff and visitors in the dining room awaiting lunch.”

An interview conducted with the facility’s Director of Nursing on May 23, 2017 “verified the exit to the 100 Wing of the facility empties into a parking lot area in which a resident could be transported through without being in full view of residents, staff and visitors in the dining area at mealtime.”

Injured through Nursing Home Abuse or Neglect at a Nebraska Facility?

Were you, or a loved one, injured through neglect, abuse or mistreatment while at any nursing facility, like Good Samaritan Society – Alliance? If so, consider filing a claim for compensation to hold those legally responsible for your injuries financially accountable. A Nebraska nursing home attorney working on your behalf can file all the necessary paperwork in the appropriate courthouse to ensure you receive adequate monetary recovery for your damages.

These cases are typically handled through contingency fee agreements. This arrangement provides you immediate access to counsel, advice and legal representation to ensure your case is handled promptly without the need for any upfront payments. All legal services are paid only after the case is resolved successfully through a negotiated out of court settlement or a jury trial award.

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